<div class="alert alert-error">
<form action="function/form_function.php" method="POST" class="form-inline">
<input type="hidden" id="from" name="from" value="symptom.php"/>
<label for="symptomName"><b>Symptom:</b> </label><br />
<input type="text" id="symptomName" name="symptomName" /><br />
<label for="symptomNote"> <b>Note: </b></label> <br />
<textarea id="symptomNote" name="symptomNote" rows="4" cols="50"></textarea> <br />	
<b>Severity</b><br />
<input type="radio" id="symptomLevel" name="symptomLevel" value="1" checked="checked"/> Mild<br />
<input type="radio" id="symptomLevel" name="symptomLevel" value="2"/> Average <br />
<input type="radio" id="symptomLevel" name="symptomLevel" value="3"/> Severe <br /><br />				

<input type="radio" id="symptomTime" name="symptomTime" value="now" checked="checked"/> Now
<input type="radio" id="symptomTime" name="symptomTime" value="custom"/> Set Time:
<input type="text" id="symptomCustomTime" name="symptomCustomTime" value="<?php echo date(DATE_FORMAT)?>"/><br /><br />


<input type="submit" name="enterSymptom" value="Enter Symptom" class="btn btn-primary pull-right"/> <br /> 

</form>
</div>
			